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Background: Rotational malalignment after operative fracture treatment of the lower extremity may be associated with increased pain and functional impairment. Despite its clinical relevance, there are no uniform management guidelines. The aim of this scoping review is to provide an overview of all available evidence to diagnose and treat rotational deformities of the lower extremity following operative fracture treatment., Methods: This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A literature search was carried out on 22 August 2023 by two independent reviewers in the Pubmed (MEDLINE), Embase, Web of Science, and Cochrane library databases. The search strategy was developed with the assistance of a biomedical information specialist. The main search terms were tibial and femoral malrotations. Disagreements were resolved through discussion with a third reviewer., Results: After screening and quality assessment of 3929 unique identified records, 50 articles were included for qualitative synthesis. Most studies were retrospective case reports or case series. Thirty studies focused on the femur, 11 on the tibia and nine included both femur and tibia. Most of the included studies presented cases where malrotation was associated with other limb deformities. Only 18 studies focused solely on the treatment of malrotation of the lower extremities after operative fracture treatment. Regarding diagnosis, bilateral CT-scans were used in 34 studies. Regarding treatment, external fixation was used in two studies, internal fixation (either intramedullary nail or plate) in 45 studies, and in three studies the authors used both. Overall, revision surgery resulted in good clinical outcomes with low complication rates., Conclusion: This scoping review reveals that rotational malalignment following operative treatment of lower extremity fractures remains an important complication. Although it occurs frequently and is associated with severe disability for the patient, standardized guidelines regarding the terminology, diagnosis, indications for intervention and treatment are lacking. CT-scan is the most used diagnostic modality in daily clinical practice. Revision surgery, using diverse operative techniques, demonstrated positive results, significantly alleviating patient complaints with few complications. Nevertheless, an international consensus regarding the optimal management pathway is needed, and future prospective clinical studies seem therefore necessary., Competing Interests: Declaration of competing interest All authors declare no conflict of interest with respect to the preparation and writing of this article., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Mechanical alignment of the lower limbs has been suggested to cause abnormal uneven loading across the compartments at the knee, but its contribution to the initiation and progression of arthritis remains controversial. This study aimed to establish whether malalignment of the lower limb after trauma is associated with worsened arthritis scores in the theoretically overloaded compartment, and if arthritis scores continuously correlate with the degree of malalignment and time with deformity., Design: After screening 1160 X-rays, 60 patients were identified with long-leg radiographs > 2 years after fracture. Measurement of mechanical axis deviation (MAD) divided into groups of varus malalignment ( n = 16, >16 mm), valgus ( n = 25, <0 mm), and normal alignment ( n = 19). Alignment and bilateral knee compartmental arthritis scores were recorded by three clinicians, compared via analysis of variance and assessed with linear regression against time since injury using MAD as a covariate., Results: In varus and valgus malalignment, there was a greater mean arthritis score in the "overloaded" compartment compared to the contralateral side, with varus medial Osteoarthritis Research Society International (OARSI) scores 5.17 ± 2.91 vs 3.50 ± 2.72 ( P = 0.006) and Kellegren-Lawrence scores 2.65 ± 1.19 vs 1.79 ± 1.24 ( P ≤ 0.001). In a linear regression model, OARSI arthritis score was significantly associated with absolute MAD (0.6/10 mm MAD, P < 0.001) and time (0.7/decade, P ≤ 0.001)., Conclusions: Malalignment consistently results in more advanced arthritis scores in the overloaded compartment, most likely related to abnormal loading across the knee. Severity of arthritis using OARSI grading continuously correlates with degree of malalignment and time with deformity after post-traumatic malunion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Preoperative planning for circular external fixators is considered vital towards achieving the best results for complex post-traumatic tibial deformities, and patient-specific 3D printed (3DP) models were used here as a planning aid. The main goal was to investigate the fidelity of the preoperative planning process, by assessing the potential to reduce operative time and determining the need to adjust pre-constructed frames intra-operatively., Patients and Methods: Nine patients (10 limbs) underwent treatment for post-traumatic tibial complications using circular external fixation. These were compared to 10 similar cases where a 3DPM was not used as a pre-operative planning aide (Control group). Patient-specific models of affected bones were printed, and preoperative planning was performed using conventional techniques and Hexapod-assisted software. Detailed planning in a virtual procedure determined osteotomy levels and identified sites for wires and half-pins. The prototype of the external fixator was locked in this optimized configuration, removed from the model, and sterilized prior to the actual procedure., Results: Nine patients with 10 limbs were treated for complications following tibial fractures. Seven were infected non-unions, and three cases were malunions. For all cases a CT based 3DP model of the full tibia was used in the preoperative planning stage. Image analysis required a mean of 1.7 h, with an average of 14.9 h to 3D print each model. In the control group (without a 3D model), the mean surgical time was 329 min (180-680). The mean surgical time in the 3DPM group was only 172.4 min (72-240), (p = 0.024), reducing the surgery time by 48%. For the 3DPM group it was not necessary to modify the preassembled frame in any case, while in the Control group, the pre-constructed frame required intra-operative modifications in 8 of the 10 cases (p = 0.0007)., Conclusion: Using patient-specific 3D models has allowed us to carry out meticulous preoperative planning sessions, eliminating the need to modify or alter the frame assembly in the operating room, saving substantial surgical time and enabling a more precise design of the apparatus. This was especially useful in multiplanar deformities and for the spatial configuration of the foot support, talus ring, and ankle ring., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Conventional cutting guides in total knee arthroplasty can potentially cause unintentional deviation from the planned direction and depth of bone resection resulting in malaligned components. The purpose of this study was therefore to investigate the accuracy of bone cutting jigs for both the femur and tibia using imageless navigation., Material and Methods: A total of 125 patients with a mean age of 66.7 ± 9.9 years underwent primary total knee arthroplasty with a Stryker Triathlon™ fixed bearing posterior cruciate retaining implant using imageless navigation. Coronal and sagittal position of the secured cutting jig was recorded and bone resection was checked with a rectangular probe attached to a navigation tracker., Results: There were significant within group differences for the femoral sagittal cut (mean δ = 0.9° [31 %]; p = 0.00001), femoral depth medial compartment (mean δ = 0.5 mm [5 %]; p = 0.001), femoral depth lateral compartment (mean δ = 0.7 mm [7 %]; p = 0.00001), proximal tibial cut (mean δ = 0.3 mm [25 %]; p = 0.001), tibial depth medial compartment (mean δ = 0.6 mm [10 %]; p = 0.0001) and tibia depth lateral cut (mean δ = 0.4 mm [5 %]; p = 0.002). Deviation of more than 2° was observed for the distal cut in the sagittal plane in 17 % and in 9.6 % for the proximal tibial cut in the sagittal plane of all patients., Conclusion: The results of this study demonstrated significant differences between the dialed in cut and "actual" bone resection achieved for all planes for both the femur and tibia. The femur sagittal cut demonstrated a tendency for an extended cut and the tibia showed a tendency for varus.

Purpose: The purpose of this study was to investigate the relation between knee functionality and posterior tibial slope in anterior cruciate ligament (ACL)-deficient and ACL-reconstructed patients., Methods: Patients with isolated ACL injuries on the surgical waiting list and patients who underwent ACL reconstruction with bone-patellar tendon-bone grafts between 18 and 24 months after surgery were recruited from the orthopaedic sports injury clinic. The study included 44 ACL-deficient patients (range 16-49) with a mean age of 26.4 years and 24 ACL-reconstructed patients with a mean age of 27.2 years (range, 25 to 49 years). Posterior tibial slope was measured on a digitalized lateral radiograph by use of the posterior tibial cortex as a reference. The Cincinnati scoring system was used to assess knee functionality., Results: The posterior tibial slope averaged 6.10° ± 3.57° (range, 0° to 17°) in the ACL-deficient group and 7.20° ± 4.49° (range, 0° to 17°) in the ACL-reconstructed group. An anterior tibial slope was not measured in any of the participants. The mean Cincinnati score was 62.0 ± 14.5 (range, 36 to 84) in the ACL-deficient patients and 89.3 ± 9.5 (range, 61 to 100) in the ACL-reconstructed patients. There was a moderate but nonsignificant correlation (r = 0.47) between knee functionality and slope in the ACL-deficient patients. When we divided posterior tibial slope into intervals of 0° to 4° (mean score, 58.4), 5° to 9° (mean score, 59.6), and greater than 10° (mean score, 75.4), a strong significant correlation (r = 0.91, P = .01) was observed between knee functionality and slope. There was a weak but nonsignificant correlation (r = 0.24) between knee functionality and slope in the ACL-reconstructed patients. When we divided posterior tibial slope into intervals of 0° to 4° (mean score, 78.2), 5° to 9° (mean score, 86.1), and greater than 10° (mean score, 89.4), a strong and significant correlation (r = 0.96, P = .0001) was observed between knee functionality and slope., Conclusions: The results of this study suggest that ACL-deficient and ACL-reconstructed patients with higher posterior tibial slope have more functional knees., Level of Evidence: Level IV, therapeutic case series., (Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.)

The axial relationship of the joints of the lower extremity reflects both alignment and orientation. Static considerations are useful for preoperative planning and deformity correction, but dynamic considerations including compensatory gait may be more relevant clinically. Laboratory animal models have been developed that simulate the deleterious effect of malalignment on articular cartilage. Malalignment disturbs the normal transmission of force across the knee, and altered stress distribution related to deformity has been demonstrated in cadaver models using pressure-sensitive film. No prospective data are available to document the natural history of malalignment, but several retrospective studies suggest the clinical course is one of gradual progression resulting in degenerative arthropathy. The long-term follow-up of fractures is less definitive, and difficult to interpret considering the bias inherent in patient selection. Although direct clinical evidence of a cause-and-effect relationship between malalignment and arthrosis has not been possible, substantial evidence from the orthopedic literature supports this hypothesis.

The authors have developed a universal system of geometric deformity planning based on the mechanical or anatomic axes. The place where the axes intersect is the center of rotation angulation (CORA) of a deformity. Osteotomy level and type should be considered relative to the CORA to avoid creating secondary deformities. This type of planning is applicable to both frontal and sagittal plane deformities.

Gradual mechanical distraction with the Ilizarov external fixator was used on 28 limbs in 23 patients to correct complex lower-extremity deformities of diverse causes. To determine the accuracy of realignment and deformity correction, the charts and radiographs were reviewed retrospectively. Preoperative long-standing anteroposterior radiographs of the entire lower extremity were compared with those obtained at the most recent follow-up visit. The parameters used to assess accuracy of correction were joint alignment and joint orientation. Alignment was determined by mechanical axis deviation (MAD) and mechanical tibiofemoral angle (mTFA). The preoperative MAD averaged 48 mm and the postoperative MAD 8.6 mm. The preoperative mTFA averaged 16 degrees and the postoperative mTFA 3 degrees. The result of deformity correction from early cases was compared with the result obtained from recent cases. Residual MAD averaged 13.2 mm in the early group and 6.4 mm in the recent group. Residual mTFA averaged 4.7 degrees in the early group and 2.2 degrees in the recent group. Gradual correction by dynamic external fixation can restore alignment and correct complex deformities with great accuracy. These results suggest the accuracy of correction increases with surgical experience.